MEDICARE: HARVEY DENNIS LEDESMA O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPT12094TPL	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467421990
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HARVEY DENNIS LEDESMA O.D.

Provider Business Mailing Address
First Line	:	6550 APPLEWOOD ST
Second Line	:
City	:	HIGHLAND
State	:	CA
Zip	:	92346-5210
Country	:	US
Telephone Number	:	909-725-1422
Fax Number	:

Provider Business Practice Location Address
First Line	:	4124 N SIERRA WAY
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92407-3825
Country	:	US
Telephone Number	:	909-883-4900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2006
Last Update Date	:	07/08/2007

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